An audible “pop” often signals a torn anterior cruciate ligament in the knee, one of the most common – and dreaded – injuries for young athletes, particularly girls. Among the approximately 150,000 ACL injuries every year in the United States, various estimates put the number sustained by women at two to eight times those suffered by men. And female athletes between the ages of 15 and 19 account for the highest number of ACL injuries.

No other common orthopedic injury is as terrifying, as disabling or as damaging to a young athlete’s career. A torn ACL requires surgery and six to nine months of recovery and rehabilitation before a return to the playing field. And having torn an ACL once increases the risk of suffering a second injury to the ligament as well as the risk of early onset of osteoarthritis in the knee. “The short- and long-term consequences of a ruptured ACL have prompted the development of conditioning programs designed to prevent the injury,” says Robert Fay, clinical director at Armonk Physical Therapy & Sports Training. “Since the factors that affect the risk of ACL injury may be different for every girl, a comprehensive evaluation by a qualified physical therapist can help each athlete undertake training that will improve her odds of staying healthy.”

The anterior cruciate ligament is one of four primary ligaments that connect the bones that comprise the knee joint. The ACL, located in the middle of the knee, connects the shinbone (tibia) to the thighbone (femur). It acts to stabilize the knee and prevent the lower leg from sliding too far forward. While an ACL rupture can result from contact, as in a football tackle, the vast majority, especially in girls, are caused by stopping suddenly, changing direction rapidly, or landing a jump incorrectly. The high school sports that put girls most at risk are the ones that require those motions: soccer, basketball, volleyball, and gymnastics.

Why do girls suffer more ACL injuries?

Starting at puberty, a surge in testosterone in boys produces more muscle, making them stronger but less flexible. Girls at puberty tend to add fat rather than muscle and their ligaments are more lax, making them more flexible but with less supporting muscle mass and strength to keep joints stable. “Biomechanical studies have also shown differences in how girls and boys use their muscles,” says Mr. Fay. “For example, they land a jump differently and they run differently, with less neuromuscular control of the knee. Fortunately, these factors can be modified with proper conditioning and the risk of ACL damage reduced.”

Preventing ACL Injuries

A physical therapist or training professional can develop a sport-specific program designed to reduce the risk of ACL injuries. These programs focus on plyometrics, balance, and exercises that improve strength and stability.

* Plyometrics are repetitive jumping exercises that are comprised of rapid, powerful movements that first lengthen a muscle then shorten it, a contraction cycle that increases muscular power. The exercises progress in difficulty using elements like squat jumps, broad jumps, and hopping. Girls are trained to land softly with a bent leg and bent hip, rather than stiff-legged.

* Balance training uses various devices – boards, discs, stability balls – and a combination of exercises performed on one leg.

* Training to improve strength and stability covers a wide range that includes focusing on the core, the gluteal muscles, and using the hamstring when landing rather than relying on the quadriceps, which puts strain on the ACL.

Training is the primary component of a strategy to minimize the risk of injury for young athletes but it isn’t the only one. “Kids are often encouraged to concentrate early – sometimes as early as middle school – on a single sport,” Mr. Fay says. “That means they’re using the same muscles every day. And with the growth of club sports, traveling teams and specialized camps, they’re playing that sport more often, even all year round. Their muscles never get a chance to recover and they have many more opportunities to get hurt. Proper conditioning, taking breaks, and playing more than one sport in the adolescent years can build strength and endurance and help support a healthy athlete for years to come.”

– Robert Fay, PT, MHSc, OCS, STC, CSCS , clinical director and owner at Armonk Physical Therapy & Sports Training, has more than 15 years of clinical experience in orthopedics and sports medicine including working with college and professional athletes.

Yogi Berra said: “You can observe a lot by watching.” I have had a front row seat as a parent of a two sport athlete, and as a trainer of primarily female teen athletes. And, as an avid fan of all sports and a former basketball player, I have watched a lot in the past 30+ years and I have observed a lot.

One of my strengths is being able to form a solid foundation of safe and age-appropriate exercise guidelines for all female (and male) athletes. Sadly, I continue – in 2014 – to see too many injuries occurring to female athletes that can be minimized if youth sports organizations and their volunteer coaches would implement single leg balance exercises for all of their participants prior to, and continuing through their teenage years as an integral part of having these athletes play their sport(s).

All female athletes experience challenges at puberty that contribute to what researchers describe as an “epidemic” of ACL [knee] injuries. They need to prepare their bodies; i.e., training to play sports as I wrote in my book: They’re Not Boys – Safely Training the Adolescent Female Athlete [2012].

The word epidemic has been used by several leading orthopedic surgeons/researchers for decades to explain their frustration with the explosion of female sports injuries that can be minimized (sports injury is an inherent risk for those who play sports) with single leg balance exercises as part of a total training program that provides functional and sport-specific training.

FACT: Single leg balance exercises with strength training will go a long way to helping female athletes. I know this based on all the value added research (more than 300 evidence-based research papers) over the past decades that support this claim. Even better validation is the more than 600 teen female athletes I have trained since 1995 using this foundation of single leg balance. Remarkably, not one female (or male) athlete has ever had an ACL injury after completing my training program; i.e., every sport and cheering.

As Tim Hewett Ph D, a leading researcher for helping female athletes said: “I was only a page or two into the prologue, when I realized that a non-contact ACL injury is, by Taleb’s definition, a “Black Swan.”

A Black Swan (Nassim Nicholas Taleb) “is a metaphor that describes an event that comes as a surprise, has a major effect, and is often inappropriately rationalized after the fact with the benefit of hindsight. The “black swan theory” refers only to unexpected events of large magnitude and consequence and their dominant role in history.”

Yes, non-contact ACL injuries are this consequential since Title IX was enacted more than 40 years ago. FACT: Female youth sport participation has exploded since Title IX. Myth: The increase in female injury rates is only due to this explosion. FALSE!! Apples to apples comparisons over the decades show the ratio of female ACL injuries is much higher by a factor of a 3-8 times higher rate than male ACL injuries. Even worse is that a vast majority of male athletes are hit while the females are non-contact; i.e., the knee just gives out.

Q angle, quadriceps dominance, and many more challenges occur at puberty and place every female athlete at risk for knee injuries. Long term consequence is OA [osteoarthritis] in the joint affected for 70%+ of all female athletes injured. Future moms should not have to deal with OA in their late twenties and beyond.

Will single leg balance exercises prevent all knee injuries? No, of course not!! But, there is no downside to safe and age-appropriate training to play sports. Training will help every female to become the best she can be and if injured, the athlete will return to play quicker than an untrained athlete.

So, all parents must understand the status quo for four plus [4+] decades now must change. You need to demand that every sports organization implement single leg balance exercise with strength training for every female athlete. Yes, it’s REALLY IMPORTANT that all female athletes train to play sports.

We need to be smarter and insist that the leaders of youth sports organizations mandate that all volunteer and paid coaches learn how to safely train all of their athletes to play their sport featuring single leg balance exercises – not several minutes before practice – and implement this training year round (everywhere there are trainers who can help implement this training). Train to play sports must become the norm for all female athletes now. IT’S TIME FOR A CHANGE NOW!!

– Mr. Potash has successfully trained more than 600 teen (and older) female athletes to play every sport since 1995 with much success. His BNP Training Program is an integrated approach that also provides quality information on eating for daily energy and sports nutrition, strategic thinking skills, how to concentrate between the lines, and more. He is also the creator and co-author of Your Lower Back (1993) and author of They’re Not Boys – Safely Training the Adolescent Female Athlete (2012). Quality information for helping all female athletes can be found online at learn2trainsafely.com.

With the beginning of fall sports starting now – female athletes and concussions are an important topic as more than 35 states have passed or are providing legislation for baseline concussion tests before a female (and male) athlete can play sports.

Baseline tests and return to play criteria for all athletes is gaining steam in State legislatures throughout the country. Arizona has passed a law for all athletes to have a baseline concussion test before their first practice.

This female population is affected due to laxity (looseness) that is present for almost all female athletes.

STRONG Necks and Concussions

Research – football players – shows that a strong neck may reduce the risk of concussion (training-conditioning.com; May/June 2012).

FACT: Females are more lax (looser) than males.

Therefore, it is no wonder that the latest research shows that the severity of a concussion is worse for females than males. Female student-athletes need to perform the necessary exercises (isometric neck strengthening and range of motion exercises) to mitigate the effects of a possible concussion. Coaches need to incorporate neck strengthening as part of the female athlete’s preparation to play sports.

Anne McIlroy [Globe and Mail; 03-18-11] wrote that females [are] more susceptible to concussion. A noted researcher says:

“The current clinical assessment protocols and return to play guidelines, which are almost entirely based on research with male athletes, are not only inappropriate for women but likely place them at a greater risk of suffering multiple concussions and experiencing long-term consequences of their injuries [per Dave Ellemberg, Ph.D.]… But female university athletes in the United States who play soccer, basketball, lacrosse and hockey have a higher risk of getting concussed than their male counterparts, says Tracey Covassin [Ph.D., ATC], a Canadian researcher at Michigan State University who began to study concussions in female athletes a decade ago. She says it is still not clear how much greater that risk is, but Ellemberg says evidence suggests that women are three [3] times more likely than men to suffer a sports-related concussion.”

“Researchers in Canada and the United States say they don’t know why women are more vulnerable to sports-related concussions, but factors may include weaker necks, subtle differences in brain chemistry, and differences in the way females are coached or train.

There are risks associated with all sports and all kinds of physical activity, Covassin says, and no one wants girls or women to stop playing hockey, soccer or other sports. She suspects that female athletes are getting more concussions because they are stronger, faster and more aggressive than in the past.

Dr. Covassin and her colleagues released a 2010 study; Tracking neurocognitive performance following concussion in high school athletes. The conclusion states that:

“Concussed athletes self-reported significantly more symptoms at 2 days post concussion and exhibited a resolution of symptoms by 7 days post injury. High school athletes could take up to 21 days to return to baseline levels for reaction time. These data support current recommendations for the conservative management of concussion in the high school athlete.”

Concussion Assessment & Management Program [CAMP]

Phil Hossler, MS, ATC is a leading trainer who has developed the Concussion Tool Kit with several associates. He tells parents of concussed athletes about three key areas:

1. Complete rest is needed

2. Second-impact syndrome, recurrent concussions

3. Involve teachers as part of the team helping your female athlete.

He lists “brain breaks” and “study buddies” as part of the process for students, teachers, and parents to consider for the concussed athlete.